Health plan for disabled adults cut back in Mass.

As insurers balk, 5 counties are excluded from experiment

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Jamal Lee, 42, who lost the use of his legs when he was shot at the age of 17, credits his current medical care group with improving his quality of life. “It’s not like dealing with a business,” Lee said. “It’s like dealing with family.”

Massachusetts health insurers’ reluctance to join a national experiment to improve care for disabled lower-income adults has forced the state to scale back the program even before it starts.

Massachusetts is among the first states to roll out the national program, but half the insurers that were expected to participate backed out because they feared losing money. That will mean fewer options for patients when enrollment opens for the voluntary “One Care” program in October.

Enrollees in most Massachusetts counties would have had four or more insurers to choose from under the original plan. Now, about half of eligible enrollees will have just one choice. Five counties — Bristol, Berkshire, Barnstable, Dukes, and Nantucket — will be excluded because no insurer signed on to serve customers there.

Insurers and policy makers in other states have faced similar challenges, in some cases delaying start dates and shrinking expectations for the program, which aims to provide intensive services and cut costs for up to 2 million people across the country with the most complicated and expensive medical needs.

“Not too many people thought it would be easy,” said Kevin Prindiville, executive director of the National Senior Citizens Law Center, who has tracked the program in each state, “but it’s turning out to be even harder than people even thought.”

Some patient advocates say a smaller, slower start may be better for vulnerable patients, allowing time to work out the inevitable kinks of any new initiative.

The program will serve low-income and disabled people, ages 21 to 64 in Massachusetts, whose health care bills previously have been covered by two government programs — federally run Medicare and state-run Medicaid — making it difficult to track and manage their care for the lowest cost and best results.

Up to 90,000 people will be eligible, down from the 109,000 who would have been eligible if more insurers had signed up, allowing coverage in all Massachusetts counties.

Three health plans have signed on: Commonwealth Care Alliance, Fallon Total Care, and Network Health. The organizations will receive one payment to provide all mental health, medical, substance abuse, dental, and long-term support services. The goal is to encourage investment in preventive services and intensive case management to avoid expensive hospitalizations.

As it became clear that the program would require more up-front investment than some policy makers and insurers had expected, the government sweetened the deal, promising to cover more of the insurers’ expected losses between the October launch date and the end of next year. In future years, the insurers hope to earn a surplus, even as the government reduces what it pays them.

But the offer wasn’t enough to keep some insurers in the program.

Boston Medical Center HealthNet, Neighborhood Health Plan, and the state’s largest insurer, Blue Cross Blue Shield of Massachusetts, had won a bid to participate but said in recent weeks that they would opt out, citing inadequate pay rates and expected losses.

Several patient groups have expressed concern that the program could result in cuts to personal care attendants or other nonmedical support services that allow people with severe needs to continue living on their own or in a community setting.

“We are OK with the fact that they’re trying to do an experiment here,” said Leo Sarkissian, executive director of the Arc of Massachusetts, an advocacy group for individuals with intellectual and developmental disabilities. “We would rather see it grow slowly and see what the issues are.”

The cost of those support services became one major roadblock for Blue Cross, said chief operating officer Bruce Bullen. The proposed pay rates did not explicitly factor in personal care attendants or dental services, he said. And, unlike others in the program, Blue Cross does not serve people on Medicaid today, so it was “more of a leap” for the insurer to create a system to serve the dually eligible, those on Medicaid and Medicare.

Representatives of BMC HealthNet, whose revenue helps to support Boston Medical Center, and Neighborhood Health Plan, owned by Partners HealthCare, also said the risk of losing money on the program was too high.

Acting state Medicaid director Kristin Thorn said she thinks the remaining insurers, all with Medicaid experience, are the right ones to launch the program.

“These three in particular have shown a high degree of collaboration, inventiveness, and a commitment to serving the complex needs of these members,” Thorn said.

Commonwealth Care Alliance, which will serve the most counties, already contracts with the state to manage care for disabled seniors. Through its clinical network, it serves other adults, many of whom probably will enroll in the new payment system come fall.

Among the alliance’s current patients is Jamal Lee, who provides a good example of the kind of patient the new program is designed for. He used to run out of his catheter supplies regularly while he or his doctors wrangled with government health insurance programs. So the 42-year-old from Quincy, who lost the use of his legs when he was shot at age 17, suffered recurring urinary tract infections, sometimes requiring a hospital stay.

That changed when Lee began getting his care through Commonwealth Care Alliance, which takes a more comprehensive approach to patient care. A nurse practitioner guided him around the bureaucratic roadblocks to get more supplies, cutting his infections from nearly monthly to three or four a year. A social worker helped him move out of a rooming house with stairs and into an apartment where he can more easily maneuver in a wheelchair.

“It’s not like dealing with a business,” Lee said. “It’s like dealing with family.”

Dr. Bob Master, chief executive of Commonwealth Care Alliance, said the program has required major investments in staff and a new electronic records system.

The group now serves about 5,000 seniors eligible for both Medicare and Medicaid, but could grow five-fold in the next three years under One Care. Master expects losses next year of several million dollars, which the state and federal government will share, but he believes the investments will pay off over time.

“We absolutely believe that we will turn this around in 2015,” he said.

One looming question is whether programs such as the one pioneered by Master’s group will be as effective when they serve many more patients. “Where we have these good models,” said Prindiville, of the national law center, “are they good because they are small?”

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